I 


UB 373 

.345 

1922 

Copy 2 


Manual of Procedure 

To be used by 

United States Army and Navy 

for 

Presenting Claims of 
Ex-Service Men 


United States Veterans’ Bureau 

Allotment and Allowance Compensation (dependents) 

Compensation (ex-service men) Insurance Claims 

Insurance Status 


Miscellaneous 

Allotment Refund (Bonus Pay) Lost Discharge 
Deceased Soldiers’ Effects Reissue of Uniform 

Deceased Soldiers’ Pay Due Travel Pay 

Deceased Soldiers’ Bonds Vocational Training 

Liberty Bonds 


Prepared by the 

United States Veterans’ Bureau 

C. R. Forbes, Director 

1922 

First Edition 



> I > 

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Washington 

Government Printing Office 
1922 













library of cong^ss 
secsived 

JJJN 28^922 

DOCUME NTS DIV13IQ . 







MANUAL OF PROCEDURE FOR PRESENTING 
CLAIMS OF EX-SERVICE MEN. 


United States Veterans’ Bureau, 

W ashington. 

Promptness in the payment of claims by the United States Veter¬ 
ans’ Bureau depends upon the completeness with which each claim is 
presented. 

If claims are submitted piecemeal, each piece must go to the file 
until by correspondence the entire list of claims requirements is as¬ 
sembled. Each such case takes up the time and attention of various 
employees, and precludes the possibility of the prompt service which 
it is desired be accorded all claims. 

Exact procedure to follow in handling each class of inquiry to¬ 
gether with such forms are needed to be filled in to make the claim 
complete are indicated. Where forms of bureaus other than the 
United States Veterans’ Bureau are omitted because of bulk, an ad¬ 
dress is given indicating where these forms may be procured, al¬ 
though each United States Army or Navy recruiting station and 
United States Army cantonment will have a supply on hand, which 
can be obtained by writing to the personnel adjutant. 

The instructions in this manual concerning other Government de¬ 
partments have been approved by each such department and are 
presented to coordinate our service and yours to ex-service men and 
their dependents. I have been glad to bring them together in order 
to place at your disposal every means of expediting to the utmost 
degree all classes of inquiries you may be called upon by ex-service 
men to make; thus carrying out the instruction conveyed by General 
Order No. 27, War Department, dated July 1, 1921, and General 
Order No. 64, Navy Department, dated August 3, 1921. 

On August 9, the Sweet bill, creating the United States Veterans’ 
Bureau providing for complete decentralization, was passed, and, in 
order that you may receive the prompt service which it is my desire 
to extend to you, it is suggested that, in all instances, claims of every 
character be presented through the nearest subdistrict office, the lo¬ 
cation of which will be found on pages 26-31. 

C. R. Forbes, Director . 


(l) 


General Orders, 1 War Department, 

No. 27. J 'Washington , July 7, 1921. 

Assistance for ex-service men in their relations with the United 
States Veterans ’ Bureau. —1. It is the purpose of the War Depart¬ 
ment, acting through its available personnel, to assist ex-service men 
in every possible wav in securing contact with the United States 
Veterans’ Bureau, thus enabling them without delay to renew or 
convert their insurance, to secure medical or dental treatment, hos¬ 
pitalization or vocational training, or to present their claims for 
compensation. 

2. The obligation is imposed upon all personnel adjutants through¬ 
out the Army, recruting officers, and Regular officers on duty with 
the National Guard and Organized Reserves, to aid their less fortu¬ 
nate comrades. Such officers will at once familiarize themselves 
with the orders and circulars relating to the United States Veterans’ 
Bureau in so far as these instructions refer to renewal or conversion 
of insurance, compensation, medical or dental treatment, hospital¬ 
ization, and vocational training, so that intelligent assistance and 
advice may be afforded ex-service men in regard to their relations 
with the bureau. 

3. The officers mentioned will obtain without delay direct from 
the United States Veterans’ Bureau a supply of all blank forms 
needed by ex-service men in their contact with this bureau. 

4. Upon application from ex-soldiers, the officers mentioned in 
paragraph 2 will furnish blank forms, will assist in the preparation 
of applications, will carefully examine all papers or instructions on 
the forms in question, and will themselves promptly forward the 
completed applications or statements directly to the United States 
Veterans’ Bureau, Washington, D. C. 

(004, 61, A. G. O.) 

By order of the Secretary of War : 


Official: 

J. T. Kerr, 

Adjutant General. 


John J. Pershing, 

General of the Armies , 

Chief of Staff. 


General Order Navy Department, 

No. 64. Washington, D. C ., 3 August , 1921. 

ASSISTANCE GIVEN EX-SERVICE MEN IN OBTAINING CONTACT WITH THE 
UNITED STATES VETERANS’ BUREAU. 

1. It is the purpose of the Navy Department to assist ex-service 
men in every possible way in securing contact with the United States 
Veterans’ Bureau, thereby enabling them to renew or convert in- 

(2) 



3 

surance, secure treatment, hospitalization, or vocational training or 
present compensation claims. 

2. To accomplish this purpose all ships and stations will at once 
familiarize themselves with the orders and circulars of the United 
States Veterans’ Bureau relating to the above-mentioned benefits, 
and receiving ships and recruiting stations will obtain from that 
bureau a supply of all blank forms needed by ex-service men in their 
contact with that bureau. 

3. Upon application from ex-Navy men all possible assistance will 
be given by receiving ships and recruiting stations in preparing 
necessary papers and blanks and forwarding to the United States 
Veterans’ Bureau. 

Theodore Roosevelt, 
Acting Secretary of the Navy. 


INDEX. 


Page. 


Allotment and allowance—war risk_ 

Allotment refund—Army and Navy_ 

Back pay—soldier, sailor, marine_ 

Bonus pay--- 

Form A-2.—Form to bonus section_ 

Compensation : 

Ex-service men_ 

Form 526.—Application for compensation and training_ 

Form 545.—Copy of discharge_ 

Dependents_ 

Form 527.—Application, dependents_ 

Description of forms_.- 

Deceased soldier: 

His effects_ 

Liberty bonds_ 

Form A-3.—Application for Liberty bonds_ 

Pay due him at death_ 

General Order No. 20—Withdrawal of bureau documents_ 

General Order No. 27—(War Department)_ 

General Order 64—(Navy Department)__ 

Insurance: 

Claims_ 

Form 501.—Emergency information_ 

Form 514.—Affidavit in support of claim_ 

Status_ 

Form A-l.—Request for information concerning converted or 

term insurance_ 

Government life insurance_ 

Synopsis of regulations Nos. 14 and 15—reinstatement require¬ 
ments _'_ 

Form No. 739.—Application for conversion to United States Gov¬ 
ernment life insurance_ 

Form No. 742.—Application for reinstatement war risk term in¬ 
surance _ 

Form No. 807.—Application for reinstatement Government life in¬ 
surance_ 


Index___.- 

Liberty bonds- 

Lost discharges_ 

Manual of Procedure- 

Red Cross—relations to bureau.i 

Reissue of uniform- 

Travel pay_ 

United States Veterans’ Bureau : 

District offices_ 

Subdistrict offices- 

Vocational training—employment 


21 

22 

31 

23 

24 


D 

6-9 

10-11 

12 

13-16 

50 


25 

26 
27 
2S 

37-38 

2 

2-3 

17 

18 
19-20 

39 

40 

41 

42-43 

44-15 

46-47 

48-49 

4 

29 

30 
1 

37 

32 

33 


34 


35-36 

34 


( 4 ) 








































COMPENSATION OF DISABLED EX-SERVICE MEN. 


Procedure .—When you find an ex-soldier, sailor, or marine who 
appears to be entitled to compensation: 

Obtain from the nearest subdistrict office, United States Veterans’ 
Bureau, Form 526, the initial claim blank, and Form 545, upon which 
discharge is to be copied, as these are required in order to present a 
claim. Form 526 should be filled out in every detail and duly signed 
by the claimant, and in addition two persons should be requested to 
witness the execution of this form. After this is done, the form 
should be acknowledged and sworn to before and duly executed by 
an officer empowered to administer oaths, or a duly-authorized repre¬ 
sentative of the United States Veterans’ Bureau. When these two 
blanks are properly filled out and duly sworn to before the proper 
official, they may either be mailed to the subdistrict office or pre¬ 
sented in person. If they are mailed, a letter should accompany the 
forms requesting that the subdistricit office authorize a medical exam¬ 
ination of the claimant; if the papers are presented in person at the 
subdistrict office, the manager in charge is empowered to authorize 
examination to be held while the claimant is waiting. 

If hospitalization is found necessary, the proper authority is 
obtainable through the medical officer in charge of the work at the 
subdistrict office. 

It is suggested that all claims concerning compensation, insurance, 
vocational training, medical treatment or hospitalization, be pre¬ 
sented through the nearest subdistrict manager wdiose address will 
be found on pages 26-31. By availing yourselves of the services of 
our subdistrict offices you will materially expedite the adjudication of 
all claims. 

All matters pertaining to war risk, vocational training, and United 
States Public Health Service, in so far as they relate to the disabled 
soldier, are now incorporated. No separate form, therefore, is neces¬ 
sary in presenting a claim for vocational training, and full instruc¬ 
tion as to the procedure in such cases is given on page 17 of this 
manual. 


( 5 ) 


6 


United States Veterans Bureau. 
Form 620—Revised August, 1921. 


C. 


APPLICATION OF VETERAN DISABLED IN THE WORLD WAR FOR 
COMPENSATION AND VOCATIONAL TRAINING 


DIRECTIONS 

READ WITH GREAT CARE 

All papers submitted with reference to this claim should bear your full name, also your rank and 
organization in the service. • 

You must furnish the information called for in this application and support your answers by the proof 
called for in the following instructions. Every question must be answered fully and clearly. Answers and 
affidavits must be written in a clear, readable hand, or typewritten. If you do not know the answer to any 
question, say so. 

I. Forward a certified copy of your certificate of discharge from the service with this application. 

II. If you have been attended by any physician since your discharge you should secure from that physi¬ 
cian a record of your case, giving the diagnosis, prognosis, the dates of treatment, and in the opinion of the 
physician, the origin, nature, ana probable duration of your disability, attaching his statement to this form. 

III. If you are married, you must submit to the Bureau evidence of your marriage by one of the follow¬ 
ing methods: 

(1) Verified copy of the public or church record; or 

(2) By the affidavit of the clergyman or magistrate who married you;.or 

(3) By the affidavits of at least two eye-witnesses to the ceremony; or 

(4) By the affidavits of two persons who know that you lived together as husband and wife and are 

recognized as such, stating in their affidavit how long such relation continued. 

IV. In making claim for additional compensation for children, evidence that they are your children 
must be submitted in any one of the following forms: 

(1) By certified copy of the public record of birth; or 

(2) By certified copy of record of baptism; or 

(3) By the affidavit of the persons showing that the records are not obtainable and giving the name 

of the child, date, and place of birth and names of parents. 

(4) If a stepchild, affidavits from two persons must be made showing that the stepchild is a member 

of the disabled soldier’s household and that the stepchild’s own father, if living, assumes 
none of the responsibility for the stepchild’s support and is receiving no dependency allow¬ 
ance for the stepchild. 

(5) If adopted child, certified copy of the court order or decree of adoption must be forwarded. 

V. If additional compensation is claimed for dependent parents, relationship must be shown in one of 
the following forms: 

(1) By certified copy of the public records of the disabled soldier’s birth ; or 

(2) By a certified copy of the church record of his baptism. 

(3) If the above are not obtainable, by the affidavits of two persons who have knowledge of the 

relationship. 

(4) If persons for whom additional compensation is claimed are foster parents, Form 524 (Affidavit 

of person claiming to have stood in the relation of parent) should be procured, filled out in 
full, executed, and forwarded with this application. If same can not be procured, state 
in answer to question No. 35, in this application, that parents are foster parents, and 
necessary forms will be forwarded to you for execution. 

VI. If additional compensation is asked for dependent brothers or sisters or others on account of whom 
maintenance and support allowance may be granted to trainees under the provisions of section 2 of the Voca¬ 
tional Rehabilitation Act, information must be furnished as called for in questions 39, 40, and 41. 

VII. If dependents of the applicant who are over 18 years of age reside abroad'or in a place remote from 
the applicant’s residence at the time this application is filed, a duplicate copy of this application should be 
sent to such dependents for the execution oi the necessary affidavits. 


PENALTY 

That whoever in any claim for family allowance, compensation, or insurance, or in any document required by this act. or by regu¬ 
lations made under this act, makes any statement of a material fact knowing it to bo false, shall be guilty of perjury and shall be pun¬ 
ished by a fine of not more than 15,000 or by imprisonment for not more than two years, or both. (Sec. 25, Act of October 6, 1917.) . 

M—«7«» 






1. Full name. 

2. Address_ 


[Page 2 of Form 526.] 

APPLICATION FOR COMPENSATION AND VOCATIONAL TRAINING 

A. PERSONAL HISTORY. 


(Last Name.) 


(First Name.) 
(City or Town.) 


(Middle Name ) 


(State.) 


(Number.) (Street.) 

3. Under what name did you serve?_ 

4. Color. Date of birth. Place of birth..... 

B. MILITARY EXPERIENCE AND RELATED INFORMATION. 

5. Make a cross (X) after branches of service you served'in: 

General Service. Limited Service. Army. Navy.* Marine Corps. 

Coast Guard. (a) Give Serial No. 

6. Date you last entered service... 

Place of entry... 

7. Date of last discharge. Place of discharge. 

8. Company and regiment or organization, vessel on which, or station in which, you last served. 


9. Rank or rating at time of discharge. 

10. Nature of discharge: Honorable.; Ordinary.; Dishonorable.Bad conduct. 

S. C. D. 

11. Nature of disability claimed. Degree of disability. 

12. Date disability began. 

13. Cause of disability. 

14. Where received. 

15. Did you receive treatment at an Army or Navy Hospital, or any other hospital?... 

(a) If so, state name and location of the hospital and dates of treatment. 


16. If the injury was caused through the fault of some person other than the United States or the enemy, 
state whether suit has been commenced against, or settlement made with such pereon on account of 

such injury: . If settlement has been made 

or damages recovered state which, and the amount:. 

C. OCCUPATIONAL EXPERIENCE. 

r 17. What was your principal occupation or trade before entering the service? 


(Occupation.) (Monthly wages.) 

18. Give any other occupation or trade in which you wero engaged: 


(Date) 


(Occupation.) 


(Monthly wages.) 


(Dates.) 

(Dates.) 


(Occupation.) (Monthly wages ) 

19. Last two employers before entering the service: 


(Employer's name.) 


(Address.) 


(Time employed.) 


(Employer’s name.) (Address.) (Time employed.) 

20. Occupations since discharge, dates of each, and wages received. If less than before! why ?. 


(Occupation.) 


(Cammonang date.) 
(Commenting date) 


(Ending date.) 
(Ending date) 
(Address.) 


(Monthly wagea ) 
(Monthly wages) 


(Full c 


(Occupation.) 

21. Present employer. 

iruu UACM.j 

D EDUCATIONAL HISTORY. 

22. How far did you go in grade school ? . In high school ? —.... 

23. What other schooling have you had, such as college, Army or Navy school, night school, correspondence 

school, etc. (Answer fully.) . 


E. MEDICAL DATA. 

24. Name and address of physicians who have since discharge attended you for your disability^ 


25. Are you confined to bed? . Do you require constant nursing or attendant? 

26. Name and address of nurse or attendant._. 

27. Are you willing to accept medical or surgical treatment if furnished ? . 


87419°—22-2 

























































8 


[Page 3 of Form 526.] 

F FAMILY OBLIGATIONS AND DEPENDENCY CLAIMS. 

28. Are you single, married, widowed, or divorced? .... 

29. Times married. Date and place of last marriage. 

30. Times present wife has been married. 

31. Do you live together? . (a) If not, state why you are not living together, and your wife ’9 

present address.. 

32. Give below the information required concerning each dependent child under 18 years of age and unmarried. 


Name or Cirn.0 

Date or Birth 

Name and Addbess or Person wtth Whom CHitn Lives 

Day 

Month 

Year 











• 
























33. If any child mentioned in question 32 is an adopted child, give name of such child and date of adop¬ 

tion. If a stepchild, give name and date 

6uch child became a member of your household. 

34. Have you a child of any age who is insane, idiotic, or otherwise pfermanently helpless? . If so, 

give name and age... 

35. Give name and address of each parent living. 


36. Age of mother.years. 

37. Age of father.years. 


38.. (a) Is your mother now dependent on.you for support? .. 

(6) Is your father now dependent on you for support ? . 

39. If compensation is claimed on behalf of either parent, or both, answer the following questions: 

(a) Are they living together? . (6) Widowed or divorced ? . 

(c) Are they incapable of self support? (Yes or no). 

[(d) If so, how is each incapacitated ? Mother. 

Father.,..'.... 

(e) The average monthly contribution you gave to your mother, $.: your father, $. 

(f) Value of all property-owned by your mother, $ .; your father, $. 

( g) What is the monthly amount of money received by your mother from all sources, $.; 

your father $. 

40. If you claim disability of father, a physician’s certificate must be attached hereto showing to just what 

extent he is incapacitated. 

41. Give the following information concerning all of your brothers and sisters. If you have none, write 

“None” in blank space below. 


Name 

Ace. 

Residence 

Masbied. 

Occupation 

Annual Income. 


















' 
































































































9 


[Tage 4 of Form 526.] 

0 . MISCELLANEOUS INFORMATION 

42. Did you make an allotment of your pay while in the service ?. 

43. If so, to whom ? ._. 

44. Give number of any other compensation claim filed on account of this disability and place where 


filed . 

45. Did you ever apply for War Risk Insurance?. (a) When?. 

(6) Where?. (c) Amount? 


46. Name of beneficiary in application for insurance .. 

47. Have you since changed the beneficiary to some other person ? 

(a) If so, to whom? . * ... 

48. Have you ever previously applied for vocational training?.. 

Give facts briefly.. 


I make the foregoing statements as a part of this application with full knowledge of the penalty provided 
for making a false statement as to a material fact in a claim for compensation, insurance, or vocational training. 


(Signature of claimant.) 


Subscribed and sworn to before me this. day of. 192 , 

by ... claimant, to whom the statements herein were fully made 

known and explained. 

[seal] ..... 

Notary Public 

We, the undersigned, severally solemnly swear that we have known the claimant whose name is sub¬ 
scribed above . years, and that we have read the statements made by him, and the facts stated 

are true to the best of cur knowledge and belief. 


(Signature of witnesj ) 


(Address of witness.) 


(Signature of witness ) 


(Address of witness.) 


Subscribed and sworn to before me this ... day of 


i92 


[seal.] 


Notary Public. 


(If no dependents over IS genre of ege ere claimed the following supporting efBdeelt should pet be esecuted) 
SUPPORTING APFIDAVIT 


State of .. 
County of 


ss: 


We, the undersigned dependents over 18 years of age, do solemnly swear, for himself and herself individ¬ 
ually, that we have read, or had read to us, the foregoing questions and answers; that we understand the same; 
that we are the persons named in said answers as dependents; and that the statements contained therein aa 
to relationship and dependency of each of us toward said applicant are true. 


(Signature of affiant.) 


(Signature of affiant.) 


(Signature of affiant ) 


(Signature of affiant.) 


Subscribed and sworn to before me this 


day of. 


192 


[seal] 


Notary Public. 























































10 


COPY OF DISCHARGE CERTIFICATE TO BE USED ONLY WITH CLAIMS AGAINST THE 
UNITED STATES VETERANS BUREAU 

ifottarable Bfadiarge 

FROM 

United states Armg 



[COPY] 


®o all tnfjnm it way rmtrmt: 

Qttfia la tu CErrltfg, That _ 


THE UNITED STATES ARMY, as a Testimonial of Honest and Faithful Service, is hereby 

ifonnrahlg liatJjargrb 

from the military service of the UNITED STATES by reason of __ 


_ __ toas bom 

in _, in the State of ___; 

when enlisted he Was _ years of age, and by occupation a _; 

he had _ eyes, -t— hair, _ complexion, and 

was __ feel _ ' inches in height. 


(Sttlftt under my hand at . . _ __ this 

» 

_ day of — _,_, one thousand nine hundred and __ 


Form SAS—Iter. Oct., 1921 


3—M3I 


CCnmmaruiinnu 

























11 


[Page 2 of Form 545.] 

ENLISTMENT RECORD 

[COPY] 

Name _ 

Enlisted or Inducted 

Serving in _ 

Prior service _ 


Noncommissioned officer __ 

Marksmanship, gunnery qualifications or rating _ 

Horsemanship _ 

Battles, engagements, skirmishes, expeditions _ 


19 _, at __ 

_ enlistment period at date of discharge. 


Knowledge of any vocation _ 

Wounds received in service _ 

Physical condition when discharged _ 

Typhoid prophylaxis completed _ 

Paratyphoid prophylaxis completed _ 

Married or single _ Character 

Remarks - 


Signature of soldier - 

hereby certify that the foregoing is a true, 
literal, and exact copy of the discharge certificate 

of -—- 


Notary Public or Summary Court Officer. 

My commission expires - 


Commanding. 


(THIS MUST BE ATTESTED BY A PERSON AUTHORIZED TO EXECUTE OATHS) 


















































COMPENSATION—DEPENDENTS. 


Procedure .—If you find a wife, child, or dependent of a disabled 
soldier, sailor, or marine, it will not be necessary for any form to be 
filled out other than initial Form 526. The additional evidence re¬ 
quired in such cases is fully explained on page 1 of Form 526 (re¬ 
vised), and before the claim is filed instructions should be followed 
in every detail, as by doing so unnecessary delay will be obviated. 

If you find a widow, chdd, or parent of a deceased soldier, sailor, 
or marine, have that person or persons fill out very carefully Form 
527—Application for Death Compensation. Instructions as to the 
execution of this form will be found on page 1 of said form and 
should be made to the subdistrict office located in the subdistrict which 
has jurisdiction over the residence of the claimant. After this form 
has been filled out entirely and all questions answered, the same 
should be forwarded to the subdistrict office mentioned above. 

The two witnesses will add their affidavits in the space provided 
on the back page. This is necessary to determine whether under the 
law the persons applying are in the class of dependent relatives to 
whom compensation is payable. 

Where applications are made for both parents, both must execute 
the affidavit; where application is made for a minor child, the com¬ 
pensation, if awarded, can be paid only to a legally appointed guard¬ 
ian; a copy of the guardian’s appointment by the court should be 
forwarded with this claim. 

This copy must be certified by the clerk of the court making the 
appointment, as a certification before a notary public is not sufficient 
under the act. 


( 12 ) 


13 


TREASURY DEPARTMENT, 
Bubxad or Was Risk Imsukancb. 
Form S87.—RsTiMd Ju, 1»19. 


Pile No. C— 


APPLICATION OF WIDOW, CHILD, or/and DEPENDENT PARENT. 


READ WITH GREAT OARE. 

This form is & blank application for compensation only. It is not a claim for insurance, which is 
separate and distinct from compensation and must be applied for on a different form. 

This application should be filled out, signed at the end, witnessed, and sworn to before an official 
empowered to acknowledge oaths. Every question must be answered fully and clearly in ink, in a clear 
readable hand, or typewritten. If the answer to any question is not known, the statement, "I don’t know,” 
will be sufficient. No award of compensation will be made until formal application has been made and the 
necessary proof has been submitted. 

If application is made on account of death that did not occur in the service, a certified copy of the public 
record of death must be submitted and, if possible, a certified copy of the deceased’s certificate of discharge 
from the service. 

A. PROOF OF WIFE. 

Marriage must be proven by a certified or verified copy of the public or church record, or the affidavit 
of the clergyman who officiated, or the affidavits of two eye witnesses to the ceremony, or the affidavits of 
two persons having personal knowledge of the marriage, together with affidavit stating why record of 
marriage is not obtainable. A widow who was divorced from a former husband must submit a certified 
copy of the court order or decree of divorce from her former spouse. 

B. PROOF OF CHILDREN. 

Ages should be proven by certified copies of the public or church record of birth, or if such records are 
not obtainable, by the affidavits of two persons. 

Stepchild: Affidavits of two persons that child was a member of deceased’s household required in support 
of a claim for compensation for a stepchild. 

Adopted child: Adoption must be shown by certified copy of court order or decree of adoption. 

Illegitimate child: Must be shown to have been acknowledged in writing by father. 

C. PROOF OF DEPENDENT MOTHER AND FATHER. 

Relationship must be proven by certified copy of the public record of birth or church record of baptism 
of the person who was injured or died in the service and the affidavits of two persons identifying the claimant 
as one of the parents named in such record, or by the affidavit of the physician, midwife, or nurse in 
attendance at the birth, or by the affidavits of two persons having personal knowledge of the relationship, 
if public records are not available. 

Dependency must be shown by affidavits of two persons, stating the amount of the total annual income 
of each parent claiming compensation, the amount received monthly by each such parent from each separate 
source, including the monthly earnings of such parent, if any, and if none, fhe reason such parent is not 
capable of self-support. These affidavits must also show the amount contributed monthly by the deceased 
or disabled person before entering the service and the location and value of all property, real and personal, 
owned by each such parent, the encumbrances thereon, and the net monthly income therefrom, as well as 
the source of the affiant’s information. 

All papers which you send this Bureau must bear the full name, rank, and organization of the person 
injured or killed in the service, as well as the file number in the upper right-hand corner of this form. 

Uli 



14 


[Page 2 of Form 527.] 

PENALTY. 

That whoever In any claim for family allowance, compensation, or insurance, or in any document required by this act or by regulation 
made under this act, makes any statement of a material fact knowing it to be false, shall be guilty of perjury and shall be punished by a 
fine of not more than $5,000, or by imprisonment for not more than two years, or both. 


1. Claimant’s full name. 


(a) Date of birth.—. 


2. Second Claimant’s name. w .. (a), Date of birth... 

3. Name of person injured or killed in service...— 

4. Date and place of his birth.... 

5. Hia relationship to Claimant(s).. 6. His color. 7. His height. 

8. His occupation before entering the service'......-...... 

(a) Weekly earuingB.....^ 

9. Date and place he last entered the service..----- ... ._......... 

10. Branch of service he served im Army..... 3 Navy...—.-.. 

Marine Corps.‘. Coast Guard. Other branch.. 

11. His rank or rating at time of last discharge..... 

12. Company and regiment or organization, vessel, or station in or on which he was serving. 

13. Describe injury suffered or disease contracted in the service causing death or disability. 


14. Did death result (a) while in the service?... (fc) If so, state amount, if any, expended by you for the return home 

and burial of the body, $ ... (c) State amount of burial expense, if any, received from Army or Navy, $.. 

15. Date of discharge from the service..... Date of death..... 

16. Date when and place where injury or disease causing disability or death was first received . 

17. Nature and extent of disability resulting therefrom.:. 

18. Occupation and weekly wages since discharge....... 

19. If disability or death occurred after dischargo or resignation from the service, state: (a) Whether cl aim for compensation was ever 

filed in this Bureau by the disabled or deceased, and if so, the file number assigned his claim....... 

(6) Whether he obtained a certificate from the director of the Bureau to the effect that at the time of his discharge or resignation 
he was suffering from injury likely to result in disability or death, and if so, the number of the certificate of disability 

...... (c) Whether ho ever applied for War Risk Insurance, and, if so, the number of 

the certificate of insurance issued him ...... 

20. Was he married or single? .. If married, how many times?. Had he been divorced? ... 

21. Date and place of last marriage............. 

cj —a_>i 2 






























15 


[Page 3 of Form 527.] 

22. Maiden name of wife, if any. 23 . I B 8 he living?_._ 

24. Were they divorced?.... 25. Her present address ..... 

26. Had she been previously married?__ 27 Was she divorced from a former husband?... 

28. If so, give date of divorce..... 29. Ras she remarried since death of husband injured or killed in tho 

service?... If so, state date of remarriage... 30 Has person disabled or deceared 


any child or children living, including adopted children and stepchildren under 18 years of age and unmarried? 

31. If so, give name aud following particulars of each child to the best of your knowledge and belief - 


Full name of child. 

Date of birth. 

- ... . ...-1 - 

Name and address of person having custody of the child. 

Day 

Month. 

Year 



























32. If any child is a stepchild, an adopted child, or an illegitimate child, state the full name of such child, whether a member of the 

household of deceased, the name of the mother and, if an adopted child, the date of legal adoption.... - 

33. Name and date of birth of any child of the person on account of whose injury or death claim is made who is insane, idiotic, op 

otherwise permanently helpless ................. 

34. Name and address of each parent of the person on account of whose injury or death claim is made.... 


35. Are they incapable of self-support?... If so, how is each one incapacitated? 

36. On whom does each depend for support? (a) Mother-- (6) father..— 

37. Did the person injured or killed in the service contribute to. their support?____ If so, what amount did he contribute 

monthly to (a) his mother_(6) his father_? (c) How much of this was for his board?- 

38. Cash value of all property, real and personal (including cash on hand and in the bank, stocks, bonds, etc.), owned by (o) mother 

__ (b) father... 

39. Name and age of each member of the household if father or mother is claimant- - —-- 



(a) Total monthly earnings of all members of household — 


87419°—22-3 



























































16 


[Page 4 of Form 527.] 

40. Amount each member of the household contributes monthly to support of each parent claiming compensation--—. 

41. Total amount received monthly by each parent from all sources: Mother, $_; father, $- (a) Amount 

of monthly earnings: Mother, f ..; father, f __ 

42. Average monthly expenses during last twelve months of each parent claiming compensation, including actual cost of rent: (a) Mother, 

$_; ( 6 ) father, $_ (Include under rent, interest on mortgage paid in place of rent.) 

43. Has claimant any other relative who was or is in the military or naval service of the United States?___. If 90 , state 

name, relationship, rank, and branch of service such relative is serving in...-.... 

44. Bid claimant ever apply for or receive an allotment of pay or allowance or compensation from the Unit 1 States or accountof any 

pereon's service?__ (a) If so, state number of said claim and date and amount of allotment, allowance, or 

I make the foregoing statements as part of my claim, with full kngwledge of the penalty provided for 
making a false statement as to a material fact in a claim for compensation or insurance. 


[Signature of claimant (wife).) 


(Address of claimant (wife).) 


[Signature of claimant '(mother).) 


[Address of claimant (mother). | 


M 


(Signature of claimant (father).) 


[Address of claimant (fatber).| 


Subscribed and sworn to before me this . day of 


19. 


by.claimants), 

to whom the statements herein were fully explained. 

Notary Public. 

We, the undersigned, severally solemnly swear that we have known the claimant(s) whose name(s) is/aro 
subscribed above ..years, and that we know said claimant(s) to be the... 

(Relationship 

...of the deceased., 

to the deceased.) (Name and service of the deceased.) 

that we have read the statements made herein, and the facts stated are true to the best of our knowledge and 
belief. 


[Signature of witness.) 


[Signature of witness ! 

Subscribed and sworn to before me this 


(Address of witness.) 
[Address of witness.) 


day of 


., 19- 


Notary Public. 





































INSURANCE CLAIMS. 


Procedure .—If person or persons apply to you believing they are 
entitled to payment of insurance on the death of a soldier, sailor, 
or marine: 

Form 501 should be given to the person applying, with the ex¬ 
planation that the execution of this form of itself does not entitle 
this person to the insurance, but it will serve as a means of identifi¬ 
cation and proper checkage against insurance records. Even though 
that person may possess an insurance certificate, this of itself does not 
entitle that person to payment under this insurance, as the soldier 
might have changed his beneficiary without notice, and for the 
further reason that many men failing to pay the required premiums 
have allowed the insurance to lapse and be of no effect. 

After this form is filled out, the records of the central office will 
be searched to disclose if the person inquiring is entitled to insur¬ 
ance. Thereby considerable time will be saved in locating the record. 

After this form has been executed and forwarded to the nearest 
subdistrict office, and a further investigation discloses that this per¬ 
son is the beneficiary and entitled to payments of insurance, he will 
be furnished from the central office with the Form 514 (revised), sim¬ 
ilar to that shown on the following page, which form is an affidavit to 
identify the person as the one legally entitled to the proceeds of this 
insurance and to further substantiate the death of the insured. 

After Form 514 has been fully executed% it should be submitted 
to the subdistrict office charged with supervision of the residence 
of the claimant, to be examined to determine if the affidavit is 
properly executed, including the seal of the official administering the 
oath, or its equivalent, and immediately forwarded to the central 
office. 


( 17 ) 


18 


Fonn.OOl (Revised Aof., mi) CUk NaC 

UNITED STATES VETERANS BUREAU 

CLAIMS DIVISION 


EMERGENCY INFORMATION 

Washington, D. C.,..,— ..~— ., 19 


It appears that.............-. 

(Name.) (Rant) (Organization.) 

who died_._, 19., gave your name and address for use in emergency. 

Kindly answer the following questions and return this form in the inclosed envelope, which requires no 
postage. The questions concerning dependency- relate solely to Compensation, which is separate and apart 
from Insurance. Dependency need not be shown by a beneficiary in order to receive Insurance. 


AttuUml Director. 


1. Your relationship, if any..... 

2. Name of his widow, if any.... 

3. Her post-office address. . . 

4. Names and addresses of his children, if any. 


5. Name and address of his mother 


6 . Was she dependent for support on deceased? 

7, Kamo and address of his father. 


8 . Was he dependent for support on deceased ?. 

9. His insurance certificate number. 

ilO. Were expenses incurred for the return home and burial of his body? 

(a) If so, by whom!.. 


(Signature) . 

(P. 0. Address) 

































19 


VETERANS' BUREAU, 

Claims Division. 

Form 5M. 

Revised July, 1921. 

AFFIDAVIT IN SUPPORT OF INSURANCE CLAIM. 


(Par. I) I, 


.. f ., residing at 

(Na uc of clamant ) 


<Strc«t and No.) 


(< u y or tow i».) 


(State.) 


believe myself to be the beneficiary of the 


insurance granted by the United States to. 

(Name of Insured.) 

who, I am informed and believe, died at.... on the.day of 


, 1^., as the result of 


and in support of my claim to such insurance I make the following statement as true to the best of my 

knowledge and belief: I Was bom on. . .... My relationship 

to...is that of..... 

(Name of insured.) (Widow, brother,etc.) 

For five years preceding his death the insured lived at the following-named places for the periods stated: 


The insured was born on 


day of 


The insured was 


married and his j parents**^' } re3 ^ e< ^ ftt the time of his death at 

(If not married, strike out“ widow and family/') 


The only surviving relatives of 


(Name ol insured.) 


within the class of spouse, child (including a stepchild, adopted, and illegitimate child)* grandchild, parent 
(including father, mother, grandfather, grandmother, father through adoption, mother through adoption, 
stepfather, stepmother, and foster parents), brother, sister, uncle, aunt, nephew, niece, brother-in-law, and 
sister-in-law, of whom I have any knowledge, are as follows: 


Full Name 

Relationship 

Aoe 

Address 

















• 












• 

(over) 

C2—1221 






































20 


[Page 2 of Form 514.] 


Full Name 

Relationship 

Aoe 

Address 

4 




• 





















I do solemnly swear that the foregoing statements are true to the best of my knowledge and belief. 


(Beneficiary's signature in full.) 

Subscribed and sworn to before me this 
-day of., 192 


Notary Public. 


(Par. II) We, the undersigned, severally solemnly swear that we have known the claimant whose name 


is subscribed above.years, and that we know said claimant to be the. 

(Relationship.) 

of...; that we have read the statements made 


(Name and service of the deceased.) 

herein, and the facts as stated are true to the best of our knowledge and belief. 


(Signature of witness.) (Address of witness.) 

(Signature of witness.) ’ (Address of witness.) 


AFFIDAVIT OF IDENTIFICATION. 


Notary Public. 


(Par. Ill) I, -„-., residing at. 

(Number.) (Street) 

in - State of ..., first being duly sworn 

according to law, depose and say that I am_years of age and that I have known___ 

.., hereinafter called the deceased, for. years; 

(Name of Insured.) J 

that the said deceased died at., in the State of.. 

on or about., and that I have seen the body and know it to be the body 

of said deceased. 


(Signature of affiant .) 

Subscribed and sworn to before me on..., 192 


PENALTY. 


“SECTION 25. That whoever in any claim for family allowance, compensation, or insurance, or in any document required by this act or by 
men Wor^igt nero^tbintw<fyearj of both’** 01 knowio ® lt t0 lalae ’ guilty of perjury and shafi be punished by a fine (jf not more tha 


Notary Public 


regulations made under 
than $5,000 or by imprisou- 
M HII 











































ALLOTMENT AND ALLOWANCE—WAR RISK. 


If you have any inquiry concerning allotment and allowance, the 
following procedure pertains: 

July 31, 1921 was fixed by law as the date of discontinuance of all 
payments of allotment and allowance by the United States Veterans’ 
Bureau, and no allotment or allowance will be paid by the United 
States Veterans’ Bureau covering any period from and after August 

The period of war risk payments of allotment and allowance runs 
from November 1, 1917 to July 31, 1921. If an amount of allotment 
or family allowance, or both, is due for any portion of that period, 
payment will be made at any time hereafter as follows: 

(1) If you desire information relative to payment or further pay¬ 
ment of allotment or family allowance due or unpaid for any period 
between November 1,1917, and July 31,1921, address your inquiry to 
the nearest subdistrict office, United States Veterans’ Bureau, giving 
the full name of the enlisted man, the company and regiment in which 
he served, and the allotment or serial number of the case. 

(2) After August 1, 1921, all allotments are voluntary and will 
be made under regulations to be provided by the Secretary of War, 
or the Secretary of the Navy, as the case may be. After August 1, 
1921, inquiries concerning allotments made by persons now in active 
service should be addressed as follows: 

Army—Finance Office, War Department, Washington, D. C. 

Navy—Navy Allotment Office, Navy Department, Washington, 
D. C. 

Marines—Major General Commandant, Marine Corps, Washing¬ 
ton, D. C. 

Coast Guards—Captain Commandant, Coast Guard, Washington, 

D. C. 

If you address your correspondence strictly in accordance with 
the foregoing and "give sufficient data to identify the person from 
whom an allotment is expected, service on these cases will be materi¬ 
ally expedited. 


ALLOTMENT REFUND—ARMY OR NAVY. 


Procedure .—If you find an ex-service man desiring refund of 
amounts erroneously deducted from his pay and not repaid during 
his service either to the allottee or to him: 

Assist the applicant, if an ex-soldier, to write to the General Ac¬ 
counting Office, War Department Division, Washington, D. C., ex¬ 
plaining his case fully and giving amounts and dates of deduction, 
Army serial number, and any information which will be of assistance. 

If the applicant is an ex-sailor or marine, he should make claim 
to the General Accounting Office, Navy Department Division, Wash¬ 
ington, D. C. 

This procedure applies to allotments which did not carry allow¬ 
ance and to Class A allotments from which exemption was claimed 
when no amounts have been paid to either the allottee or to the ex- 
service man. 


( 22 ) 


BONUS PAY. 

Procedure. — If you find a soldier who has not received his $60 
bonus: >> 

Cause him to fill out Form A-2, which follows this page, and 
which you may obtain from Room 1115, United States Veterans’ 
Bureau, Washington, D. C. 

Have him inclose it with his original discharge, on the back of 
which he has written his mail address. (Note. —Payment also will 
be made on a copy of the discharge certificate only if it is certified 
to by a United States Army recruiting officer.) Mail the discharge 
and the form to the Finance Office, TJ. S. Army, Lemon Building, Wash¬ 
ington, D. C. 

His discharge and the $60 bonus will be sent direct to him. 

If he previously has done this and has not heard from it within a 
reasonable time, write, giving his full name, serial number, organi¬ 
zation, and address, together with all details of the situation and 
the place and date of his discharge, to nearest United States Vet¬ 
erans’ Bureau Office, who will take it up promptly. 

Note.— The bonus is not payable to (1) any person who did not 
arrive at his camp or station before midnight of November 11, 1918; 
(2) any person entitled to retirement pay; (3) heirs or legal repre¬ 
sentatives of a deceased person; (4) anyone discharged or sepa¬ 
rated from the service under conditions not honorable. 

Navy .—Released, discharged, or disenrolled members’ applica¬ 
tions go to “ Disbursing Officer, Bureau of Supplies and Accounts, 
Navy Department, Washington, D. C.” 

Marine Corps .—Those applications go to “ Paymaster, U. S. Ma¬ 
rine Corps Headquarters, Washington, I). C.” 

Coast Guard .—Those claims go to “Allotment Disbursing Officer, 
Coast Guard Headquarters, Washington, D. C.” 

(23) 


87419°—22- i 



24 


From: __1_, Serial No. _ 

To: Finance Officer, Bonus Section, Washington, D. C., or 

To: Disbursing Office, Navy Department, Washington, D. C. 

Subject: Bonus. 

1. I respectfully make application for the $60 bonus for dis¬ 
charged service men, inclosing herewith my discharge certificate, 
and in connection herewith submit the following information con¬ 
cerning my service: 

Place of enlistment_ Date_ v _ 

Organizations in which I served:_ 


Place of discharge__ Date_ 

2. My mail address, to which I desire the bonus and my discharge 
certificate sent, is: 


A—2. 


(Sign on above line.) 


C 












DECEASED SOLDIER—EFFECTS. 


Procedure .—If you find a relative of a deceased soldier who has 
not received the soldier’s effects: 

Assist that relative to prepare a letter having at the top the soldier’s 
name, organization, and serial number, and giving in the letter the 
date and place of death, which will be sent to The Adjutant General, 
IT. S. Army, Washington, D. C. 

Two blanks will be returned, one to be filled out before a notary 
public with two witnesses. When completed, please return them as 
directed on the forms. These effects will not contain his money, 
back pay, or Liberty bonds, which are obtained from other Govern¬ 
ment departments. 


( 25 ) 


DECEASED SOLDIER—LIBERTY BONDS. 


Procedure .—If you find a relative of a deceased soldier who be¬ 
lieves the soldier left Liberty bonds wholly or partly paid for: 

Assist him to fill out the form shown on the following page, A-3, 
which may be obtained from the Finance Officer, United States 
Army, Washington, D. C., or, in the case of a sailor or marine, apply 
to the General Accounting Officer, Navy Department Division, 
Washington, D. C. 

When this is completed and every question answered accurately, 
please forward to the State United States Veterans’ officer, who will 
check it against his files and will mail it to Finance Officer, IT. S. Army, 
Washington, D. C.; or General Accounting Officer, Navy Department Divi¬ 
sion, Washington, D. C. 

It will be explained to the inquirers that filing this claim does not, 
by itself, entitle them to bonds; that these bonds are delivered to 
that person who under the laws of the State in which the soldier 
resided would be entitled to his personal property in the event he 
died without leaving a will. 

Some of these bonds will be delivered finally by the Comptroller 
General, General Accounting Officer, War Department Division, 
Washington, D. C., but all must be checked first by the Finance 
Officer. If, in replying, you are notified that the claim has been 
sent to the Comptroller General, you will know that the claim is on 
the way to prompt settlement. 

Note. —If you apply also, in a separate claim, for pay due the 
soldier at time of death, the method for which is explained on 
another page, even though you have followed the above direction 
for obtaining Liberty bonds, include in your application for pay 
due at death a statement you also wish the Liberty bonds; this is so 
that the Comptroller General may check up with the Finance Officer. 

( 26 ) 


27 


APPLICATION FOR LIBERTY BONDS, DECEASED SOLDIER. 


1921. 


Sir : 


(Full name of deceased.) 


(Rank.) 


(Organization.) 


Army Serial No. 


enlisted 


19_, and while stationed at 


(Organization.) 


(See note.*) 


as a 


(Rank.) 

_, made an allotment to the 

for Liberty Loan Bonds of the 


_issue on_19_ 

(Second, Third, or Fourth.) 

Payments on this allotment were completed_, 19-, 

while deceased was a_ 

(Rank.) (Organization.) 

Date of death_, 19- I believe myself 

legally entitled to these bonds and request that they be sent to me at the follow¬ 
ing address: 

(Full name of applicant.) 


(Mail address.) 


Relationship to deceased 


* Third and Fourth Liberty Loan allotments were to the Secretary of the Treasury. 
Second Liberty Loan allotments were to the Federal Reserve Bank of New York. 

A—3. 



























DECEASED SOLDIER, SAILOR, OR MARINE—PAY DUE AT DEATH. 


Procedure. —If you find a relative of a deceased soldier, sailor, or 
marine seeking pay due him at death: 

Assist the relative to prepare a letter, at the top of which has been 
written the name, organization, and serial number of the deceased, 
to be sent to the Comptroller General, General Accounting Office, 
War Department, War Department Division, Washington, D. C., 
or Navy Department, Washington, D. C. 

The letter should give a list showing the names, ages, and mail 
addresses of the living relatives of the service man in the following 
classes: Wife, children, grandchildren, parents, brothers, and sisters. 

The Comptroller General will send the relative the proper blank 
which you can assist in filling out with two witnesses, and then re¬ 
turn direct to the General Accounting Officer, War or Navy Depart¬ 
ment Division. 

Please see that each question is answered accurately and com¬ 
pletely before forwarding it. 

This is to procure the pay which was due the soldier, sailor, or 
marine at the time of his death, together with all sums he had de¬ 
posited with the quartermaster, or Navy supply officer, and does not 
include Liberty bonds, which he has paid for; method of obtaining 
them is explained on the following pages. 

Note. —Even though you have applied separately, in accordance 
with directions on page 19 for Liberty bonds, be sure to mention 
them in this application for lost pay, so that the Comptroller Gen¬ 
eral may check up with the Finance Officer before making settlement. 

( 28 ) 


LIBERTY BONDS. 

Procedure .—If you find a soldier who has not received his Liberty 
bonds : 

Assist him to fill out the affidavit form covering the particular 
bond issue about which he inquires, which forms may be obtained 
from the Finance Officer, United States Army, Washington, D. C., 
or, in the case of a sailor or marine, apply to the Disbursing Officer 
of Supplies and Accounts, United States Navy, Washington, D. C. 

When making out this form, be sure that for each month he not 
only states the name of the organization in which he was serving, 
but also the place at which he was stationed that month. 

Note. —Inquiries concerning Victory bonds (fifth issue) purchased 
by persons who have been discharged from the service should be ad¬ 
dressed to Finance Officer, United States Army, Washington, D. C., 
Victory Bond Section, or, in the case of a sailor or marine, apply 
to the Disbursing Officer of Supplies and Accounts, United States 
Navy, Washington, D. C.” In all inquires great care should be taken 
in having the date of discharge correct; if possible, this should be 
verified from the discharge certificate of the soldier. 

( 29 ) 


LOST DISCHARGE. 

Procedure .—If you find a soldier who has lost his original dis¬ 
charge certificate : 

Help him to fill out Form 214, A. G. O., which you may obtain 
from The Adjutant General, Washington, D. C., or in the case of a 
sailor or marine, the proper form may be obtained from the Bureau 
of Navigation, Navy Department, Washington, D. C. 

With two witnesses, have the form filled out carefully and accu¬ 
rately and sworn to before you. When it has been completed for¬ 
ward to The Adjutant General, with a request that the certificate be 
sent direct to the soldier. 

In this connection it is well to remember that a lost or destroyed 
discharge certificate can not be duplicated or replaced, the certificate 
of service is simply a certificate of what the records show in Wash¬ 
ington, and does not give battles, wounds, or honors. 

After it has been received, the soldier may write to The Adjutant 
General and ask permission to return it to have entered upon the 
face of it this information. In making such a request, the soldier 
should indicate the names and dates of the battles, giving the organ¬ 
ization in which he served in each; the places and dates where he was 
wounded, with the name or number of the field hospital, evacuation 
hospital, or base hospital which treated his wounds, and the dates and 
order number under which he was issued medals. 

This should not be included in the original request for a certificate 
of service, for, however strange it may seem, time can be saved by 
making independent requests as indicated. 

In making this request the certificate should not be sent until The 
Adjutant General says he is ready and sends for it. 

( 30 ) 


BACK PAY. 


If you find an ex-soldier who has not deceived his back pay, he 
should write a letter over his signature, giving his name, rank, organ¬ 
ization, serial number, date and place of discharge, date and place 
where last payment was received and period for which payment is 
due. This letter should be addressed to 

The General Accounting Office, 

War Department Division, 

1734 New York Avenue, 

Washington, D. C. 

An ex-sailor or marine should address his communication to 

The General Accounting Office, 

Navy Department Division, 

Washington, D. C. 

Inquiries regarding retainer pay should be addressed to the 

Navy Disbursing Officer, 

Bureau of Supplies and Accounts, 

Navy Department, 

Washington, I). C. 

( 31 ) 


REISSUE OF UNIFORM. 


Procedure .—If you find a soldier who believes he is still entitled 
to part of his uniform equipment: 

Advise him that the last appropriations bill passed by Congress 
repealed the provisions for reissue of uniform on and after June 1, 
1921. 

All applications for uniform which were on file with the Office of 
Director of Purchase and Storage, Supply Division, Clothing and 
Equipage Section, on or before June 1 , 1921, will be issued, but no 
applications will be entertained after that date. 

( 32 ) 


TRAVEL PAY. 


Procedure .—If you find a soldier who has not received his travel 
pay from place of discharge to his place of enlistment or bona fide 
residence at the rate of 5 cents per mile: 

Remember the extra travel allowance is paid only to enlisted men 
honorably discharged after November 11, 1918. A blank form of 
application Form 2847, which contains the necessary affidavit for 
the additional travel allowance, may be obtained from the nearest 
United States Veterans’ Bureau Office, the Finance Officer, United 
States Army, Washington, D. C., or any Army recruiting officer. 
This affidavit must be accompanied by a true copy of the soldier’s 
discharge certificate certified to only by a recruiting officer, or by the 
original discharge certificate, on the back of which he has written 
his name and mail address (the original discharge will be returned 
with his check). If he had submitted a certified copy for payment of 
the $60 bonus, he should say so in his application for travel pay, and 
then need not send another one. 

All travel pay claims should be forwarded to Finance Officer, 
United States Army, Lemon Building, Travel Allowance Division, 
Washington, D. C. 

If the soldier claims as his actual bona fide home or residence a 
place different from that on his service record he must send also an 
affidavit by himself and other affidavits by two disinterested persons 
all sworn to before a notary public or other person authorized to 
administer oaths, which affidavits must state— 

(A) Where he actually resided at the time he entered service. 

iB) How long he had resided there. 

(C) His occupation during that time and for whom he worked. 

(D) Where he traveled to when discharged. 

(E) Where he is now residing. 

(F) Whether he was asked at time of discharge to what place he 
desired the War Department to send him, or to what place he wanted 
the Government to pay his transportation. 

(G) Place and date of discharge and name of man by whom he 
was last paid. 

A sailor must write direct to Travel Claims Section, Bureau of 
Supplies and Accounts, Navy Department, Washington, D. C. 

( 33 ) 


VOCATIONAL TRAINING—EMPLOYMENT 


Procedure .—If you find a discharged disabled person or one about 
to be discharged with a disability who is unable to return to employ¬ 
ment because of his disability: 

You should advise him to write to the district office or subdistrict 
office of the United States Veterans’ Bureau for the territory in 
which he resides, advising that he desires to make application for 
vocational training. The office concerned will send him the neces¬ 
sary forms to be executed and will start the necessary procedure to 
obtain a medical examination of the claimant. You can assist the 
applicant in filling out the papers and fully answering the questions 
to establish his eligibility for vocational training. 

A list of the district offices and subdistrict offices throughout the 
country showing the States they comprise will be found on pages 
25-31 of this manual. 

UNITED STATES VETERANS’ BUREAU. 

DISTRICT OFFICES. 

January 1. 1920. 

Dist. No. 

1. —District Manager, Dr. A. E. Brides, Washington-Esse,x Building, Boston, 

Mass. Maine, New Hampshire, Vermont, Massachusetts, Rhode Island. 

2. —District Manager, Mr. Henry G. Opdycke, 23 West Forty-third Street, New 

York, N. Y. New York, New Jersey, Connecticut. 

3. —District Manager, Dr. L. B. Rogers, 140 North Broad Street, Philadelphia, 

Pa. Pennsylvania, Delaware. 

4. —District Manager, Mr. Albert E. Haan, Room 206, Arlington Building, 

Washington, D. C. District of Columbia, Maryland, Virginia, West 
Virginia. 

5. —District Manager, Mr. M. Bryson, 433-439 Peachtree Street, Atlanta, Ga. 

North Carolina, South Carolina, Tennessee, Georgia, Florida. 

6. —District Manager, Col. Dallas B. Smith, New Hibernia Bank Building, New 

Orleans, La. Alabama, Mississippi, Louisiana. 

7. —District Manager, Mr. William M. Coffin, 408 Pioneer Street, Cincinnati, 

Ohio. Indiana, Ohio, Kentucky. 

8. —District Manager, Mr. Chas. W. Spofford, Eighth Floor, Leiter Building, 

Chicago, Ill. Illinois, Michigan, Wisconsin. 

9. —District Manager, Mr. Middleton E. Head, 6801 Delmar Boulevard, St. 

Louis, Mo. Nebraska, Iowa, Kansas, Missouri. 

10. —District Manager, Mr. Carl D. Hibbard, 509 Keith-Plaza Building, Min¬ 

neapolis, Minn. Minnesota, North Dakota, South Dakota, Montana. 

11. —Acting District Manager, Dr. John C. Cornell, Tenth Floor, United States 

National Bank Building, Denver, Colo. Wyoming, Utah, Colorado, New 
Mexico. 

12. —District Manager Maj. Louis T. Grant, Lincoln Realty Building, 883 

Market Street, San Francisco, Calif. Arizona, Nevada, California. 

13. —District Manager, Mr. Lewis C. Jesseph, 6147 Arcade Building, Seattle, 

Wash. Washington, Idaho, Oregon. 

14. —District Manager, Mr. Sherman C. Kile, 1503 Pacific Avenue, Dallas, Tex. 

Oklahoma, Texas, Arkansas. 


( 34 ) 


35 


Subdistrict offices. 


1 . 


District. 


State. 


Suboffice. 


Boston, Mass 


Maine. 

Massachusetts 


Bangor. 
Portland. 
Lawrence. 
New Bedford. 
Springfield. 


2. New York, N. Y 


N ew Hampshire 
Rhode Island.. 

Vermont.. 

Connecticut. 

New Jersey.... 

New York. 


Worcester. 

Manchester. 

Providence. 

Burlington. 

Hartford. 

New Haven. 

Camden. 

Newark. 

Albany. 

Binghamton. 

Buffalo. 

Poughkeepsie. 

Rochester. 


3. Philadelphia, Pa 


4. Washington, D. C 


5. Atlanta, Ga 


6. New Orleans, La. 


7. Cincinnati, Ohio 


Delaware.... 
Pennsylvania 


District of Columbia 
Maryland. 

Virginia. 

West Virginia. 


Florida. 

Georgia. 

North Carolina 

South Carolina 
Tennessee. 

Alabama. 


Louisiana. 
Mississippi 
Indiana... 


Kentucky 


Syracuse.. 

Utica. 

Wilmington. 

Allentown. 

Erie. 

Harrisburg. 

Johnstown. 

Pittsburgh. 

Scranton. 

Williamsport. 

Washington, D. C. 

Baltimore. 

Cumberland. 

Norfolk. 

Richmond. 

Roanoke. 

Bluefield. 

Charleston. 

Clarksburg. 

Wheeling. 

Jacksonville. 

Macon. 

Savannah. 

Charlotte. 

Raleigh. 

Columbia. 

Chattanooga. 

Jackson. 

Knoxville. 

Memphis. 

Nashville. 

Birmingham. 

Gadsen. 

Mobile. 

Montgomery. 

Lafayette. 

Shreveport. 

Jackson. 

Meridian. 

Evansville. 

Indianapolis. 

South Bend. 

Hopkinsville. 

Lexington. 

Louisville. 







































36 


Subdistrict offices —Continued. 


District. 


State. 


Suboffice. 


7. 


Cincinnati, Ohio (cont)_ 


Ohio. 


8. Chicago, Ill. 


Illinois. 


Michigan. 


Wisconsin 


9. St. Louis, Mo. 


Iowa. 


Kansas. 


Missouri 


10. Minneapolis, Minn. 


11. Denver, Colo. 


12. San Francisco, Calif. 


Nebraska. 

Minnesota.... 

Montana. 

South Dakota. 
North Dakota. 
Colorado. 

New Mexico.. 

Utah. 

Wyoming. 

Arizona. 

California.... 


Nevada. 

13. Seattle, Wash. Idaho. 

Oregon. 

Washington. 

14. Dallas, Tex. Arkansas... 

Oklahoma.. 
Texas. 


Canton. 

Cleveland. 

Columbus. 

Dayton. 

Toledo. 

Centralia. 

Danville. 

East St. Louis. 
Peoria. 

Rockford. 

Springfield. 

Detroit. 

Grand Rapids. 
Jackson. 
Marquette. 
Saginaw. 

Eau Claire. 

Green Bay. 

Madison. 

Milwaukee. 

Cedar Rapids. 
Des Moines. 

Fort Dodge. 
Waterloo. 

Salina. 

Topeka. 

Wichita. 
Chillicothe. 
Kansas City. 
Springfield. 
Kearney. 

Omaha. 

Duluth. 

St. Paul. 

Helena. 

Fargo. 

Sioux Falls. 
Colorado Springs. 
Pueblo. 
Albuquerque. 
Salt Lake City. 
Casper. 

Phoenix. 

Tucson. 

Fresno. 

Los Angeles. 
Sacramento. 

San Diego. 

Reno. 

Pocatello. 

Portland. 

Spokane. 

Tacoma. 

Fort Smith. 

Little Rock. 
Oklahoma City. 
Tulsa. 

El Paso. 

Fort Worth. 
Houston. 

San Antonio. 
Texarkana. 

Waco. 









































37 


No. 18 . 


FIELD LETTER. 

U. S. Veterans’ Bureau, 

December 10 , 1921 . 


relations of the red cross to the veterans’ bureau. 

District managers are directed to attach to their receiving offices 
personnel of the Red Cross hitherto engaged in assisting the ex- 
service man with his problems. Because of the character of the work 
performed by the American Red Cross now and hitherto, and the 
relations which it has maintained with large numbers of people 
throughout the United States, the organization can be of the greatest 
benefit in enabling the Government to discharge its obligations to 
disabled soldiers. 

The Veterans’ Bureau, being strictly a governmental agency, is 
often prevented from performing work that is essential to the wel¬ 
fare of the ex-service men and their dependents, particularly in mat¬ 
ters of domestic finances and relations, family illness, etc. There are 
unfortunate cases which for legal reasons the Bureau can not assist 
and cases that require aid while the Government investigates the 
facts. The Red Cross is the one great agency of a quasi-govern- 
inental character that can be of extreme assistance in this direction. 

It is the general understanding with the Red Cross that so soon as 
a sufficient corps of competent persons is trained by the Bureau to 
give the soldier and his problems the special treatment which they 
require, this type of work will be relinquished by the Red Cross, but 
in the meantime the services of the organization will be used to the 
fullest extent. It is especially understood that the Red Cross work 
carried on in hospitals will be continued as heretofore. 

For the reasons outlined it is important that the fullest possible 
information be placed within the reach of the Red Cross representa¬ 
tives in the field. If certain unusual and special cases require the ad¬ 
mission of Red Cross personnel to the files, this would be permissible, 
subject to the rules dictated by good office management, such rules 
not of course permitting the removal of files from the file room, which 
it is essential that they be immediately available at all times. 

C. R. Forbes, 

Director , U. S. Veterans' Bureau. 


U. S. Veterans’ Bureau, 

August 12,1921. 


GENERAL ORDER NO. 20. 

Subject: Documents contained in the files of the Veterans Bureau 
and information in regard to transactions of an official character. 
The following general order is hereby promulgated for the ob¬ 
servance of all officers and employees of the Veterans’ Bureau : 

No account, document, or paper of any kind shall be withdrawn 
from the files of the Bureau by agents, attorneys, or other persons; 
and copies of any accounts or papers shall not be furnished to any 



38 


person except upon the written order of the Director, and such 
copies shall be furnished only to such persons as may have a personal 
material interest in the subject matter of the papers. An affidavit 
setting forth the interest of the applicant and showing the purpose 
for which copies are desired must be submitted with each application. 

Except as otherwise herein provided, in all cases where copies of 
documents or records are desired by or on behalf of parties to a 
suit, whether in a court of the United States or any other, such copies 
shall be furnished to the court only, and on a rule of the court upon 
the Director of the Veterans’ Bureau requesting the same. Excep¬ 
tions to this rule will be made only on the written order of the 
Director. 

In cases where suit instituted in a district court of the United 
States under the war risk insurance act, copies of documents or 
records may be furnished the Department of Justice or its officers 
by the general counsel of the Veterans’ Bureau. 

No information in regard to transactions of an official character 
in this Bureau is to be communicated to anyone not authorized to 
receive the same. 

No information in regard to the claim of any person which has 
ever been filed in the Bureau is to be given to any person unless 
proper authority is shown by way of power of attorney, or by letters 
of administration, or otherwise in a manner satisfactory to the 
Director. 

All other general orders or instructions in conflict herewith are 
modified accordingly. 

C. R. Forbes, 

Director , U. S. Veterans’ Bureau. 


INSURANCE STATUS. 

Procedure .—If you have an inquiry regarding the status of a serv¬ 
ice man’s insurance: 

Assist him to fill out the form following this page, Form A-l, 
which may be obtained either from the nearest subdistrict office or 
from the United States Veterans’ Bureau, Washington, D. C., 
Room 1115. 

After each question is answered accurately and completely, forward 
to Insurance Division, United States Veterans’ Bureau, Washing¬ 
ton, D. C. 

(39) 


40 


REQUEST FOR INFORMATION CONCERNING CONVERTED OR TERM 

INSURANCE. 

To enable the United States Veterans’ Bureau to identify your inquiry and 
determine exactly the status of your insurance, please answer each of the 
following questions carefully and forward to the Insurance Division, United 
States Veterans’ Bureau, Washington, D. C. 

1. My full name is_ 

(First name.) (Middle name.) (Last name.) 

2. My present address is_ 

3. I applied for war risk insurance- 

(Give approximate date.) 


(Give date of additional.) 


4. While stationed at_ 

(Original.) (Additional.) 

5. Home address as given on application was--- 

6. Date of birth_ 

7. War risk insurance granted under Certificate No- 


8. Rank and organization at date of application 


(Army serial number.) 

9. Date of discharge_ 

10. Place of discharge_ 

11. Rank and organization at date of discharge_ 


12. Last month for which premium was deducted from pay_ 

13. Premium rate at date of discharge_ ** _ 

14. The following payments have been made on war risk, or term insurance 

since discharge: 


Amount. 

Transmitted by. 

Covered 
by re¬ 
ceipt No. 

Dated. 

Teller 

No. 






















If application for conversion to permanent Government insurance has 
been submitted, give the following information: 

15. Date of application for conversion_ 

16. Form of policy_ 

17. Amount of policy___ 

18. Number of policy_ 

19. Amount still carried under war risk, or term, insurance_ 

20. The following payments have been made on the new policy. 


Amount. 

Transmitted by. 

Covered 
by re¬ 
ceipt No. 

Dated. 

Teller 

No. 






















A—1. 














































GOVERNMENT LIFE INSURANCE. 


Government life insurance is divided into two important divisions: 
First, renewable term insurance; second, level premium (Govern¬ 
ment life converted) insurance. 

YEARLY RENEWABLE TERM INSURANCE. 

This form of insurance was adopted for use of the period of the 
war and for a limited period thereafter. If protection is desired 
beyond March 4, 1926, term insurance must be converted into some 
form of level premium insurance. 

The premium rate for yearly renewable term insurance is the net 
rate according to the American Experience Table of Mortality and 
interest at 34 per cent per annum, computed for payment on a 
monthly basis. This premium rate increases from year to year as 
the insured grows older and becomes prohibitive in later years. 
Yearly renewable term insurance is payable only in monthly install¬ 
ments of $5.75 for each $1,000 insurance in force. 

LEVEL PREMIUM OR CONVERTED INSURANCE. 

The fact that the premium on yearly renewable term insurance in¬ 
creases from year to year and becomes prohibitive in later years made 
it necessary to provide insurance at a premium rate which would 
remain the same throughout the premium-paying period. 

The forms of policies provided by the Government are as follows: 
Ordinary life, twenty and thirty payment life; twenty and thirty 
year endowment, and endowment at age 62. All policies provided a 
selection of options by the insured as to settlement, including settle¬ 
ments in one sum or in monthly installments covering various periods 
of months in multiples of 12* They also provide that beneficiaries 
may elect certain options. These options are clearly set forth in the 
policy. 

All forms of policies are participating, which means that if losses 
are less than provided for by the American Experience Table of Mor¬ 
tality and the interest earnings are greater than 34 per cent, a sum 
will accrue due to such deferred mortality and excess interest earn¬ 
ings and from this sum dividends may be declared and paid. 

All forms of policies provide for total permanent disability bene¬ 
fits, and there is no charge in the premium for this protection. There 
is no limit as to the age of the insured when such total permanent 
disability may begin. . 

The Government is not in competition with commercial companies 
and it is urged that no statements be made concerning them. If an 
insured states a certain policy is better than the Government s policy, 
have him secure a specimen with rates and send it to the Assistant 
Director, Insurance Division, and a comprehensive and unbiased 
comparison will be made of the two policies and forwarded both to 
the insured and the field representative. 

( 41 ) 


42 


A BRIEF SYNOPSIS OF REINSTATEMENT REQUIREMENTS AS PRO¬ 
VIDED FOR IN REGULATIONS NOS. 14 AND 15. 

UNITED STATES GOVERNMENT TERM INSURANCE. 

Term insurance which has lapsed or has been canceled may be 
reinstated in whole or in part under the following provisions: 

A. Within three calendar months, including the calendar month 
for which the unpaid premium was due, provided the applicant is in 
as good health as he was at the due date of the premium in default 
and forwards with his application for reinstatement (first page of 
Form 742 or Form 744 complete) a remittance covering two premiums 
on the amount of insurance to be reinstated, one for the month of 
grace and one for the current month. 

B. After the expiration of the three calendar months mentioned in 
clause A, and prior to March 4, 1926, provided the applicant is in 
good health and submits an application for reinstatement (Form 
742) completely executed, with a remittance covering two premiums 
on the amount of insurance to be reinstated, one for the month of 
grace and one for the current month. 

If term insurance is reinstated under the provisions as outlined 
above for the purpose of conversion, but one premium on the term 
insurance and the first monthly, quartely semiannual, or annual 
premium on the converted insurance is necessary. 

UNITED STATES GOVERNMENT CONVERTED INSURANCE. 

United States Government converted insurance which has lapsed 
may be reinstated in whole or in part under the following provisions: 

A. Within three calendar months, including the calendar month 
for which the unpaid premium was due, provided the applicant is in 
as good health as he was at the due date of the premium in default 
and forwards with his application for reinstatement (first page of 
Form 807 or Form 744 complete) a remittance covering all premiums 
in arrears, with interest from their several due dates at the rate of 5 
per cent per annum. 

B. After the expiration of the three calendar months mentioned in 
clause A, provided the applicant is in good health and submits an 
application for reinstatement (Form 807) completely executed, with 
a remittance covering all premiums in arrears with interest from 
their several due dates at the rate of 5 per cent per annum. 

REINSTATEMENT OF UNITED STATES GOVERNMENT TERM OR CONVERTED 

INSURANCE FOR THOSE SUFFERING FROM DISABILITY OF A SERVICE 

ORIGIN. 

Where the applicant is unable to comply with requirements as 
outlined above as to his physical condition, either term or converted 
insurance may be reinstated, provided that the applicant’s disability 
is a result of an injury or disease or of an aggravation thereof 
suffered or contracted in the active military or naval service during 
the World War: Provided further , That the applicant during his 
lifetime submits proof satisfactory to the Director showing the serv- 


43 


ice origin of the disability or aggravation thereof, and that he is not 
totally and permanently disabled. 

If the insurance is reinstated under this provision, it is necessary 
to pay all monthly premiums which would have become payable if 
the insurance had not lapsed, together with interest at the rate of 5 
per cent per annum, compounded annually, on each premium from 
the date said premium is due. Form 742 for term and Form 807 for 
converted insurance, completely executed, used in these cases. 


44 


UNITED STATES VETERANS BUREAU 
Insurance Division 
Form 73d— Rev. Dec., 1921 . 

APPLICATION FOR CONVERSION TO U. S. GOVERNMENT LIFE INSURANCE 


IN ACCORDANCE WITH THE PROVISIONS OF THE WAR RISK ACT AND BUREAU REGULATIONS 

SERIAL NUMBER _ 


USE INK AND MAKE SEPARATE APPUCATION FOR EACH PLAN OP INSURANCE APPLIED POR. 


4MTY NAME IN FULL: First. MJddle. Last name. 

(Please print or type.) 




2 


HOME ADDRESS: 
Number. 


Street or rural route. 


County, city, town, or poet office. 


Slate. 



MAILING ADDRESS: 


_ 1 WAS City. town, or poatTOce. State. Day ot month. Month. 

3 BORN AT 

t 


Year. 


Ago nearest 
birthday. 


Weight. 


Height. 


Color of hair. 


Color of eyea. 


Race and nationality. 


Rank and organization at time of discharge. 

Rank, grade, or rating. erg&niratian, regiment, station, ship, etc. 


Date of enlistment. 


Date of discharge. 


Amount of War Riak Term Insurance. 


Laat month for which term 
g premium waa paid. 


Monthly term premium paid. 


10 


Certificate number. 


11 


I APPLY FOR $. 


. S. GOVERNMENT 

I WILL PAY PREMIUMS AS INDICATED BELOW: 

LIFE INSURANCE ON THE FOLLOWING PLAN: 

(Makecross mark X under plan selected.) 

12 

(Make cross mark X under method selected.) 


Ordinary LUe. 

20-Pay. Lite. 

30-Pay. Lite. 

Monthly. 

Quarterly. 

Semiannually. 


Annually. 

20-yr. Endowment 

30-yr. Endowment. 

Endowment at age 62. 





• 6 




1 ... 

$. 

1 . 

J 



If the applicant herein be entitled to this Insurance under the War Risk Insurance Act, amendments thereto and regulations made thereunder, this insurance shall 
be considered os granted and shall become effective as follows: On the first of the month succeeding the date of this application provldod the premium on an equal 
amount of Yearly Renewable Term Insurance, payable on the first of the current month, has been paid. II, however, the premium on an equal amount of Yearly 
Renewable Term Insurance, payable od the first of the current month, has not been paid, then the converted Insurance shall take effect on the first of the current 
month; but in no event shall the converted insurance take effect until the first premium thereon has been paid. 


BENEFICIARY OR BENEFICIARIES OF INSURANCE HEREIN APPLIED FOR IN CASE OF MY DEATH. 




Amt. of Ina. 

Post-office address. 

Relationship to me. 

Name of beneficiary. 

for each 

(a) Namber and street. 

(11 married woman her own Christian name and husband's 

beneficiary. 

(6) City, town, or post office. 


surname must be stated.) 

4 


H IN ADDITION TO THE CONVERTED INSURANCE ABOVE APPLIED FOR 1 WISH TO RETAIN i_. YEARLY 

RENEWABLE TERM INSURANCE. . 


15 


I SELECT THE OPTION INDICATED BY CROSS MARK X BELOW (see reveroe aide tor Instrucffens): 
No. 1 (_) one earn._. | No. 2 (.) payable In.limited Installments. 


1 Have you ever made application tor Government 
10 compensation or pension? 


17 


It so, state when and give your claim number. 


Nfl^ 3 (-) continuous Installments. 


- Are you now disabled on account ot Injury or 
18 disease? 


The applicant must remit with this application a sum not leas than the amount ot the first premium on the converted insurance applied for. 
10 I Droit • I 

Ay I inclose herewith.remittance payable to the TREASURER OF THE UNITED STATES by { Money order \ in 


cover the first.....premium on the converted insurance. 

(Write abovo whether monthly,quarterly, set 


. pret 
smiannual, or annual.) 


(Check 


the amount of I. 


to 


SIGNED AT .. 


ON THE.. DAY OF 


192 


WITNESSED BY 


ADDRRSS 


(Applicant sign here. Lk> not print signature?.) 


e2—MO« 
































































45 


[Page 2 of Form 739.] 

OPTIONAL SETTLEMENTS OF UNITED STATES GOVERNMENT LIFE 
INSURANCE (CONVERTED INSURANCE) AT DEATH 

These features do NOT apply to the term (wartime) Insurance 


,^ e . Insured may select one of the optional settlements set forth below, but notice of the selection shall not be valid unices and 
until it is recorded m the United States Veterans Bureau. Tho Insured may revoke his selection of the optional settlement, but the 
revocation shall not be valid unless and until it is recorded in the United States Veterans Bureau. If the Insured does not select ono 
of said optional settlements, then he shall be deemed to have made no election and the insurance nh«ll be payable in two hundred 
and forty monthly installments, unless an election under option 2 or 3 is made by the beneficiary. 

If the Insured has not made an optional selection at the maturity of this policy by death a designated beneficiary or beneficiaries 
may select settlement under options 2 or 3 as set forth below, but the selection shall not be valid unless and until it is recorded in the 
United States Veterans Bureau. If the Insured has made an optional selection at the maturity of this policy by death a designated 
beneficiary may elect to receive such insurance in installments spread over a greater period of time than that selected by the Insured. 

The values shown in the following options are based on an insurance of $1,000 without indebtedness. If there is indebtedness, or 
the Insured has received any payments on account of total permanent disability, the values will be decreased accordingly. If the 
policy provides for a larger amount of insurance than $1,000, the values will be increased proportionately. 


OPTIONAL SETTLEMENTS IN LIEU OF MONTHLY INSTALLMENTS OF $5.75 
PAYABLE ON THE DEATH OF THE INSURED UNDER THE TERMS OF THE POLICY 


Option 1. INSURANCE PAYABLE IN ONE SUM. Settlement under this option will bo made only when selected by the 
Insured during hia lifetime or by his last will and testament. When such selection has been made the faco amount will 
be payable in one sum at the maturity of tho policy by death. 

Option 2. INSURANCE PAYABLE IN LIMITED INSTALLMENTS. Tho installments noted below will be payable for an 
agreed number of months (not less than 36) to the designated beneficiary, but if such beneficiary dies before the agreed 
number of monthly installments have, been paid, tho remaining unpaid monthly installments will be payable in 
accordance with the beneficiary provisions of tne policy. 


Number of monthly installments_ 

30 

.48 

60 

72 

. 84 

96 

108 

120 

132 

Amount of each monthly installment. 

$29.19 

$22.27 

$18.12 

$15.35 

$13.33 

$11.90 

$10.75 

$9.83 

$9.09 

Number of monthly installments_ 

144 

156 

168 

180 

192 

204 

216 

228 

240 

Amount of each monthly installment. 

$3.40 

$7.94 

$7.49 

$7.10 

$G. 76 

$6.47 

$6.20 

$5.97 

$0.75 


Option 8. INSURANCE PAYABLE'IN CONTINUOUS INSTALLMENTS. The installments noted below will be payable 
throughout the lifetime of the designated beneficiary, but if the designated beneficiary dies before 240 such installments 
have been paid, the remaining unpaid monthly installments will be payable in accordance with the beneficiary 
provisions of the policy. 


Age of bene¬ 
ficiary at timo 
of ufcuth of 
Insured. 

Amount of Install¬ 
ment. ‘ 

Age of bene¬ 
ficiary St time 
of death of 
Insured. 

Amount of install¬ 
ment. 

Ace of bene¬ 
ficiary at time 
of death of 
insured. 

Amount of install¬ 
ment. 

Age of beno- 
ficiary at time 
of aeatb of 
insured. 

Amount of install¬ 
ment. 

10 

$3. 67 

30 

$4.11 

60 

$5.07 

70 

$5. 75 

11 

3. 69 

81 

4 15 

51 

5.13 

71 

5. 75 

12 

3.70 

32 

4.18 

52 

5.19 

72 

5. 75 

13 

3.72 

33 

4.22 

53 

5.24 

73 

5.75 

14 

3.73 

34 

4. 2G 

64 

0.29 

74 

5. 75 

15 

3. 75 

35 

4.30 

55 

5.35 

75 

5.75 

16 

3.77 

8C 

4. 34 

56 

6. 39 



17 

3. 78 

37 

4. 38 

67 

5.44 



18 

3.80 

33 

4.43 

68 

5. 48 



19 

3.82 

39 

4. 48 

69 

6. 53 



20 

3.84 

40 

4. 52 

60 

5. 56n 



21 

3.87 

• 41 

4.57 

61 

5.60 



22 

3.89 

42 

4. 63 

02 

5. 63 



23 

3.91 

43 

4. 68 

63 

5. 65 



24 

3.94 

44 

4.73 

64 

5. 68 



25 

3. S6 

45 

4.79 

65 

5. 70 



26 

3.99 

46 

4.8-1 

60 

5.71 



27 

4.02 

47 

Y90 

67 

5. 73 



28 

4 05 

49 

4.96 

63 

5.74 



29 

4.03 

49 

5.01 

69 

5.74 




C2-SS04 













































46 


UNITED STATES VETERANS BUREAU 
Iwsuiancb Division 
Form 741—Revised Oct., 1031 


.APPLICATION FOR REINSTATEMENT OF. YEARLY RENEWABLE 

TERM INSURANCE 


Applicant must fill out and sign the first page of application for reinstatement in every case. If insurance has lapsed for more 
than toroe months, the Medical Examination on the other side is also required. 


1. MY NAME IN FULL. (First.) 

(Middle ) 

(Last.) 

2. Term Insurance certificate nura- 

(Please print or type.) 



ber. 




T-.. 


3. HOME ADDRESS. (Street or rural route.) (City, town, or port office.) (State.). 

(Number.) 


MAILING ADDRESS. 


.... •» .. 

4. I hereby apply lor the reinstatement of $.....term insurance granted to me under the previsions el the War Rlak Insurance Act, which has now 

lapsed because I failed to pay the premium for the month of ... 19__ or within the grace period of 31 days. Ae a condition to the 

reinstatement of this Insurance. I do boreby certify that the answers to the following questions are true to the best ol my knowledce and belief. 


&» Are you now In as good health as you were at the due date of the premium In default?.-. 

6. Are you at present suffering from any disability which la the result of an Injury or disease, or of an aggravation thereof, suffered or contracted in the active military or 
naval servioe durtnrthe World War? (Ifno, give full details as to the nature of such disability, disease, or Injury,'where aod when«centrscted, and what treatment. 
If any, Is being received at this time.) 


r-•JM'v::. :-; 

<>-a. Are you new pei eminently and totally disabled? 


T. Have yon ever made application for 

8. If so, state when and where filed and for what disability. 

9. Give your claim namber. 

Government cempen&otieu or pen- 


if any. 

aion? 




10. Have you contracted any disease or suffered any Injury since lapse of this insurance? It so, state full particulars, date, name, and address of physician. If one attended 
you. 


11 . Have you consulted a physician In regard to your health stnee lapse of this Insurance? li so. state full particulars, date, name, and address of physician. 


» 


12. It lr agreed that the effective date of the term insurance, if reinstated, shall be the first day of tho . 
month in which the requirements have been complied with, anlees the applicant requests the 
Bureau in writing that the effective date shall be the first day of the following month. 

1 desire this reinstatement to be effective (check below): 

□ The first day of the month in which Che requirements have been compiled with, or 

□ The first day of the following month. 


13. PREMIUMS TENDERED WITH 

APPLICATION. 

(a) For first month ol lapse..$_ 

(b) For month of.. 


14. Signed ol 

the .... 


day of 


_on this 


19_ 


Reinstatement of Term Ins.$ 

(a) Advance premium on Term Insur¬ 
ance.$ 


Wits east 


(Signature of applicant.) 


(d) For first payment on $. 

Government (converted) Insur¬ 
ance.• t_ 


1 check | 

draft V Total.... I 

M.O.I 


: Use (b), (c), (d), as they may apply to your case. 


Section 25 of the War Risk Insurance Act provides that - Whoever • • • makes eny statement of a material tact knowing It to be false, shall be guilty et perjury 
and shall bo puulaheil by a fine of iwrt xuon> than $5,000, or by impel—aal far not more than two years, ai both.* * 1 iua» 






































































47 


[Page 2 of Form 742.] 

MEDICAL EXAMINATION 

Thi» examination is necessary only where insurance has lapsed for a period of more than three months. 


1. APPLICANT'S OWN STATEMENT 


!• Date of birth. 


2. Place of birth. 


3. Race. 


4. Single, married, or widowed 


5. Family 
record- 

Age It 
living. 

Health good or toad. 

(If not good, give full details ) 

Age at 
death. 

Cause of deetb. 

Year of 
death 

Father... 






Mother.. 






Slater. 






Brother. 

















6. What operations have you had? Give dates. 

7. Have you ever used 
wine* or liquors to ex¬ 
cess? 

8. Have you ever used 
opium, morphine, co¬ 
caine, or other habti- 
formlng drugs? 

9- What to your occupation? 


10, Hare you ever been treated for any disease o! brain or nerve* .... throat or lunge.heart or Mood vessels __ atomach. Uver, Inteetlnes , . .., kidney 

or Plodder ....... gen Ifo urinary organa., akin.bones.glands.... ear or eye.? (Anawer "Yea" or "No" by each. II "Yea," 

describe hilly and give date.) ^ 


11* Are you now In good health? 

Signed by applicant In the presence of medical eiamlner on this.... 

. .day of.. ......... 

. 19 - 


---- . - 

(Signature of applicant ) 

* 


2. MEDICAL EXAMINER S REPORT 


12. Height In shoes 


13. Weight, coet and vest otf. 

14. Girth of chest, normsl .In. 


15. Olrth of abdomen. 

.ft. 


Est.-fba. or weighing . .. lbs 

Forced expiration In: forced inspiration 

hi. 

ta. 


16. STATE PULSE RATE: 

(t) Before exercise.... (c) One minute after exercise.. 

(b) Immediately after exercise. (d) Two minutes after exercise 


IT. Blood pressure (see Note). 

Systolic . D issto IK . 

Instrument used 


18. Any Irregularity 
or atherotnsf 


19. After an examination do you find any abnormality of the lungs.heart ., nervous system.. skin.ear.. eye. 

or digestive system.F (Answer "Yes" or "No" by each. If "Yes." describe fully.) 


abdomen.* 


20. URINALYSIS: 

Specific gravity....... Albumin 


Reaction 


..... Test used 

Sugar.. Test used 


Have you knowledge that the urine exam¬ 
ined was passed by the applicant at the 


time of examination? 


21. Has applicant ever had syphilis, gout, or 
rheumatism? 


22. Any dsfects In the sight or bearing? 


23. Any deformity or departure from normal In any 
respect? 


24. Has the applicant lost an eye, hand or 
arm, foot or leg? 


25. Ia the ability to work Impaired In any way? If 
state particulars. 


26. Do you recommend acceptance of the rUk? 
1st Cl. risk Fair risk Poor risk 


27* Are you related to applicant 
by blood or marriage? 


28. Was this examination made at your home or office, or at applicant's 
home? State place and address. 


29. Are answers to questions of medical exam* 
Iner's report In your own handwriting? 


30. FEMALES: 




Any hlsionr of uterine or ovarian 

diseases? 

Married: If pregnant, month 

Date of last confinement. Was It normal? 

Number of miscarriages. If any, and 

advanced. 


dates. 


31. Are you satisfied that everything has been fully stated regarding the physical condition, habits, personal and family history of the applicant?. 

82. REMARKS: 


Examination made and signed this............day oL...... 

(Name of State In which you are licensed to practice medicine ) 


19. 


(Signature ) 


NOTES.—Blood pressure Is required (s) when applicant la more than thirty years of age. (b) In all cases where there Is a family history of apopleiy, heart disease, or 
oophrltls; or where there la s personal history of goat, rheumatism, syphilis, heart disease, or any evidence ol kidney disease. 

Section 25 of the War Risk Insurance Act provides that "Whoever • • • makes any statement of a material fact knowing It to be false, shall be guilty of perjury 
and thell be punished by a fine >f not mors than *5,000, or by Imprisonment for not more than two years, or both." io*n 

r o o▼ m t.7*t ricmi»o omcm 































































































































48 


UNITED STATES VETERAN8 BUREAU 
Insurance Dfvision 
Form 807—Revised Nov., 1921 


APPLICATION FOR REINSTATEMENT 
OF GOVERNMENT LIFE INSURANCE 


Applicant must fill out and sign tho first page of application for reinstatement in every case, 
than three months, the Medical examination on reverse side of this form is also required. 


1» My name In fulL (First.) (Middle.) (Last name.) 

( Please print or type.) 


S. My home address (Street and No.) (City, town, or post office.) 


If insurance has lapsed for more 

2, policy number, 

_ K-_ 

(flute.) 


Mailing address_________...........___..._......_.....__________ 

4.1 hereby apply lor the reinstatement oi $.Government LUe Insurance granted to me under the provlalona of the War Rlik Insurance Act, now 

lapsed for the nonpayment of premium for the month of..... 192 « or within the grace period of thirty-one diva. Aa a condition 

to the reinstatement of this insurance, 1 do hereby certify that the answers to the following questions are true to tho best or my knowledge and belieL 


6. Are you now In as good health as you were at the due date of the premium in default? __________...___....... 

6. Are you at present sufferlngfrom any disability which is the result of an Injury or disease, or of an aggravation thereof, suffered or contracted In the active military or 
naval service during the world War? (If so, give fuU details as to tho nature of such disability, Ulaeaso, or Injury, where and when contracted, and what treat¬ 
ment, If any, la being received at this time.)................ . . 


7. Have you contracted any disease or Buffered any Injury since lapse of this Insurance? 11 so, state full particulars, date, and name and address of ptpalctan, if one 


attended you. 


8. Havo you consulted a physician in regard to your health since lapse of this Insurance^ H so, state full particulars, date, name and address of physician..* 


w 

9* Are vou now permanently and totally disabled?.—..... 

18. Premiums tendered with application: 


(a) Total oi all premiums In 

arrears.. 9_...__ 

10. Have you ever made application lor Government compcnaation or pension? ....--—...-....... r 

tt» Interest on premium to date.. S.... 


(O) Payment of any Indebtedness 

on my policy...$... 


(Check, 1 

Remitted tm Draft, [Total --... ---- 

12. Give your claim number. If any. —. 

• lei* o., j , 

A loan or other Indebtedness may be reinstated In accord¬ 
ance with terms of the policy. 


14. Signed at_..._....___on this the ---day at ........_______ —132... 


WITNESS: 


(Signature of applicant.) 


NOTE.— Section 25 of tho War Risk Insurance Act provides that 44 Whoever • • • makes any statement of a material tad,. k nowing'll Co be false, shall be guilty 
a perjury and shall be puniahed by a fine of not more than 95,000, or by impriaaemoat for not more than two yean, or both.** 


% 

















































































49 



[Page 2 of Form 807.] 

MEDICAL EXAMINATION 

Thin p,*min»ti«n i« necnwa ty only where insurance has lapsed for a period of more than three months. 

1. APPLICANT’S OWN STATEMENT 


1. Date of birth. 2. Place ol birth. 

3* Race. 

4. Single, married, or widowed 

5. Family 
record. 

Age If 

living. 

Health good or bad. 

(If not good, give full detail*.) 

Age at 
death. 


Cause of dcat 

h. 

Year of 
death 

Father _ . . 






Motbar .. 






Slater 






Brother. 

















6. What operations have you had? Gtve dates. 

7. Have you ever used 
wines or liquors to ex¬ 
cess? 

8. Have you ever used 
opium, morphine, co¬ 
caine, or other bablt- 
formtng drugs? 

9* What Is your occupation? 


10. Hire r»a erer bem treated tor any disease ol brain or nerrce.throat or lun*».. heart or blood veaael*. .stomach, Uver, Intestines .... kidney 

* -* en J to i «**nary organs.. akin.bones-, glands., sar or eye_? (Answer '‘Yes'* or "No” by each. If "Yes," 

aeacrios rally ana give date.) 


!!• Are you now In good health? 


Signed by applicant In the presence of medical examiner on tbls.day of.. 

___ _ _ (Signature of applicant.) 


.... 19.. ... 


2. MEDICAL EXAMINER'S REPORT 


12. Height In shoes. 

.ft. ..in. 

13. Weight, coat and vest off. 

Fst. lbs. or weighIng_lb*. 

14. Girth of chest, normal .to. 

Forced expiration- In; forced Inspiration In. 

15. Girth of abdomen. 

...in. 

16. STATE PULSE RATE: 

(a) Before exercise. (c) One minute after exercise. 

17# Blood pressure (see Note). 

Systolic . Diastolic... 

18. Any irregularity 
or atheroma? 

(b) Immediately after exercise. (d) Two minutes after exercise. 

Instrument U6*d . 


19* Alter an examination do you find any abnormality ol the lungs.heart.. nervous system.. skin.. 

or digestive system.? (Answer ••Yes" or "Ifo” by each. If "Ye3," describe fully.) 


_.ear.., eye.abdomen. 


20. URINALYSIS: Have you knowledge that the urine exam- 

Specific gravity... Albumin_____ Test used.. ..... ined was passed by the applicant at the 


/Reaction.-. Sugar. Teat used.. Mine ef examination? 


21 * Has applicant ever had syphilis, gout, or 
rheumatism? 

22. Any defects In the sight or bearing? 

23. Any deformity or departure from normal In any 
respect? 

24. Has the applicant lost an eye, hand or 
arm, toot or leg? 

25* la the ability to work Impaired In any way? If so, 
state particulars. 

26. Do you recommend acceptance of the risk? 

1st Cl. risk. Folr risk- . Poor risk. 

27. Are you related to applicant 
by blood or marriage? 

28. Was this examination made at your home or office, or at applicant’s 
home? State place and address. 

29. Are answers to questions of medical exam¬ 
iner’s report in your own handwtltlng? 

30 . FEMALES: 

Any history of uterine or 

diseases? 

ovarian 

Married: If pregnant, month 
advanced. 

Date of last confinement. Was It normal? 

Number of miscarriages. If any. and 
dates. 


3l» Are you satisfied that everything has been fully stated regarding the physical condition, habits, personal and family hlatory of the applicant?—.... 


32 . REMARKS: 


Examination mode and signed this. 


..day of— 


19_ 


(Name of State In which yon are licensed to practice medicine.) 


(Signature ) 


NOTES -Blood pressure is required (a) when applicant la more than thirty years of ago. (b) in all cases where there Is a family history of apopleTy, heart disease, or 
•epbritU; or where there is a personal history ol gout, rheumatism, syphilis, heart disease, or any evidence ol kidney disease. 

Section 25 ol the War Risk Insurance Act provides that "Whoever • • • makes any statement of a material tact knowing It to be false, shall be guilty of perjury 
.and shall be punished by a fine ol not more Uun 15 , 000 , or by Imprisonment lor not more than two yev* or bolh^ aoTttJO<x * x flcan , q amcm 


02—10201 




























































































































50 


LIBRARY OF CONGRESS 



0 034 076 524 2 . 


DESCRIPTION OF FORMS. 


Form No. 

501.—Emergency information. 

506.—Investigation brief. 

512.—Letter asking for further information as to relatives. 

514.—Affidavit in support of insurance claim. 

524.—Affidavit of person claiming to have stood in relation of parent. 

526. —Application of person disabled in and discharged from the service. 

527. —Application of widow, child, or/and dependent parent. 

530.—Letter requesting additional information as to the identity of claimant. 

532. —Notice of unclaimed mail—requesting correct address from postmaster. 

533. —Abstract of marriage certificate. 

534. —Abstract of certificate of baptism. 

541.—Affidavit in proof of insurance claim. 

545.—Abstract of certificate of discharge. 

547.—Affidavit of identification. 

556. —Surrender of pensions of gratuity. 

557. —Letter asking evidence in proof of widow’s claim to automatic insurance. 
562.—Application for insurance by guardian of minor beneficiary. 

562-A.—Letters requesting information as to designation of beneficiary. 

562-B.—Letter requesting written evidence by insured to identify insurance 
application. 

567. —Request to American Red Cross to field investigator for completion of 

proof in insurance case. 

568. —Letter requesting further information, as Form 526 is incomplete. 

577.—Claim of parent for automatic insurance. 

581. —Letter asking vocational claimant regarding war-risk insurance claims. 

582. —Letter regarding pay to Federal board. 

583. —Letter to ex-service man requesting information as to claim. 

667.—Request for affidavits to connect disability with service. 

686. —Letter requesting claimant to submit additional affidavit to connect dis¬ 

ability with service. 

687. —Letter asking claimant to report for a physical examination. 

689.—Letter explaining to claimant what affidavits are necessary to connect 
disability with service. 

2545.—Report of physical examination from United States Public Health Service 
(Vocational.) 

2507.—Request for physical examination. 

2519. —Letter requesting additional medical evidence. 

2520. —Letter requesting additional medical evidence. 

2522. —Affidavit regarding claimant’s disability. 

2523. —Physician’s statement. 

2524. —Follow-up for 2507. 

2527.—Request for additional medical evidence. 


o 


